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Clinical nutrition and patient care

Nutritional care in children with cystic fibrosis: are our patients becoming better?

Abstract

Over the last 30 years, major advances have occurred in our understanding of the disorder cystic fibrosis (CF) with the discoveries of the underlying chloride transport defect and the ‘CF gene’, the CF transmembrane conductance regulator gene. Equally important from a clinical and patient perspective are the improvements in median survival from less than 10 to 20 years prior to 1980, approaching 30 years during the 1980s and over 45 years more recently. Improved antibiotic regimens and lung clearance therapy contributed to the enhanced survival, but a key factor accredited as adding a further 10 years to the median survival was improving and then maintaining normal growth and nutrition. In the main, the latter were achieved by adherence to a ‘high-fat high-energy’ diet rather than the advocated virtually universal policy of the ‘low fat’, which was associated with wasting and linear growth failure. The high-fat diet in conjunction with better control of malabsorption due to microspheric pancreatic enzyme replacement therapy, attention to adequate fat-soluble vitamin supplementation and newborn screening has ensured that at least 80–90% of children with CF will achieve better health and survival through their adult years.

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References

  1. Quinton PM . Chloride impermeability in cystic fibrosis. Nature 1983; 301: 421–422.

    Article  CAS  Google Scholar 

  2. Gaskin KJ, Durie PR, Corey M, Wei P, Forstner G . Evidence for a primary defect in pancreatic HCO3 secretion in cystic fibrosis. Pediatr Res 1982; 16: 554–557.

    Article  CAS  Google Scholar 

  3. Riordan JR, Rommens JM, Kerem BS, Alon N, Rozmahel R, Grzelczak Z et al. Identification of the cystic fibrosis gene: cloning and characterization of complementary DNA. Science 1989; 245: 1066–1072.

    Article  CAS  Google Scholar 

  4. Rommens JM, Iannuzzi MC, Kerem B, Drumm ML, Melmer G, Dean M et al. Identification of the cystic fibrosis gene: chromosome walking and jumping. Science 1989; 245: 1059–1065.

    Article  CAS  Google Scholar 

  5. Bear CE, Li C, Kartner N, Bridges RJ, Jensen TJ, Ramjeesingh M et al. Purification and functional reconstitution of the cystic fibrosis transmembrane conductance regulator (CFTR). Cell 1992; 68: 809–818.

    Article  CAS  Google Scholar 

  6. Dodge JA, Lewis PA, Stanton M, Wilsher J . Cystic fibrosis mortality and survival in the UK: 1947-2003. Eur Respir J 2007; 29: 522–526.

    Article  CAS  Google Scholar 

  7. Corey ML . Longitudinal studies in cystic fibrosis. In: Sturgess JM, (ed.) Perspectives in Cystic Fibrosis. The Imperial Press Ltd: Toronto, Canada, 1980, pp 246–255.

    Google Scholar 

  8. Cystic Fibrosis Canada. Canadian Cystic Fibrosis Patient Data Registry report. 2009. http://www.cysticfibrosis.ca/assets/files/pdf/CPDR_ReportE.pdf (accessed August 2011).

  9. Phelan P, Hey E . Cystic fibrosis mortality in England and Wales and in Victoria, Australia 1976-1980. Arch Dis Child 1984; 59: 71–73.

    Article  CAS  Google Scholar 

  10. Waters DL, Wilcken B, Irwig L, Van Asperen P, Mellis C, Simpson JM et al. Clinical outcomes of newborn screening for cystic fibrosis. Arch Dis Child Fetal Neonatal 1999; 80: F1–F7.

    Article  CAS  Google Scholar 

  11. Berry HK, Kellogg FW, Hunt MM, Ingberg RL, Richter L, Gutjahr C . Dietary supplement and nutrition in children with cystic fibrosis. Am J Dis Child 1975; 129: 165–171.

    CAS  PubMed  Google Scholar 

  12. Durie PR, Bell L, Linton W, Corey ML, Forstner GG . Effect of cimetidine and sodium bicarbonate on pancreatic replacement therapy in cystic fibrosis. Gut 1980; 21: 778–786.

    Article  CAS  Google Scholar 

  13. Forstner GG, Gall G, Corey M, Durie PR, Hill RE, Gaskin KJ . Digestion and absorption of nutrients in cystic fibrosis. In: Sturgess J, (ed.) Perspectives in Cystic Fibrosis: Proceedings of the 8th International Congress on Cystic Fibrosis. Imperial Press Ltd: Mississauga, ON, Canada, 1980, pp 137–148.

    Google Scholar 

  14. Kuo PT, Huang NN . The effect of medium-chain triglycerides upon fat absorption and plasma lipids and deposition of fat of children with cystic fibrosis of the pancreas. J Clin Invest 1965; 44: 1924–1929.

    Article  CAS  Google Scholar 

  15. Soutter VL, Kristidis P, Gruca MA, Gaskin KJ . Chronic undernutrition, growth retardation in cystic fibrosis. Clin Gastroenterol 1986; 15: 137–155.

    CAS  PubMed  Google Scholar 

  16. Parsons HG, Beaudry P, Dumas A, Pencharz PG . Energy needs and growth in children with cystic fibrosis. J Pediatr Gastroenterol Nutr 1983; 2: 44–49.

    Article  CAS  Google Scholar 

  17. Durie PR, Newth CJ, Forstner GG, Gall DG . Malabsorption of medium-chain triglycerides in infants with cystic fibrosis: correction with pancreatic enzyme supplements. J Pediatr 1980; 96: 862–864.

    Article  CAS  Google Scholar 

  18. Duhamel DJ, Lenoir G, Brouard J . Prise en charge nutritionelle des nouveau-nés et nourrissons atteints de fibrose kystique du pancréas et dépistés à la naissance. Proceedings of the International Conference on Neonatal Screening for Cystic Fibrosis. ; 5–6 October 1988; University of Caen, Caen, France; pp 183–199.

  19. Bell L, Durie P, Forstner GG . What do children with cystic fibrosis eat? J Pediatr Gastroenterol Nutr 1984; 3 (Suppl 1), 137–146.

    Article  Google Scholar 

  20. Roy CC, Darling P, Weber AM . A rational approach to meeting macro- and micronutrient needs in cystic fibrosis. J Pediatr Gastroenterol Nutr 1983; 3 (Suppl 1), 154–162.

    Google Scholar 

  21. Parsons HG, Beaudry P, Pencharz PB . The effect of nutritional rehabilitation on whole body protein metabolism of children with cystic fibrosis. Pediatr Res 1985; 19: 189–192.

    Article  CAS  Google Scholar 

  22. Shepherd R, Cooksley WG, Cooke WD . Improved growth and clinical, nutritional, and respiratory changes in response to nutritional therapy in cystic fibrosis. J Pediatr 1980; 97: 351–357.

    Article  CAS  Google Scholar 

  23. Levy LD, Durie PR, Pencharz PB, Corey ML . Effects of long-term nutritional rehabilitation on body composition and clinical status in malnourished children and adolescents with cystic fibrosis. J Pediatr 1985; 107: 225–230.

    Article  CAS  Google Scholar 

  24. Boland MP, Stoski DS, MacDonald NE, Soucy P, Patrick J . Chronic jejunostomy feeding with a non-elemental formula in undernourished patients with cystic fibrosis. Lancet 1986; 1: 232–234.

    Article  CAS  Google Scholar 

  25. Gaskin KJ . The impact of nutrition in cystic fibrosis: a review. J Pediatr Gastroenterol Nutr 1988; 7 (Suppl 1), S12–S17.

    Article  Google Scholar 

  26. Corey M, McLaughlin FJ, Williams M, Levison H . A comparison of survival, growth, and pulmonary function in patients with cystic fibrosis in Boston and Toronto. J Clin Epidemiol 1988; 41: 588–591.

    Article  Google Scholar 

  27. Gaskin KJ, Allen JR . Exocrine pancreatic disease including cystic fibrosis. In: Duggan C, Watkins JB, Walker WA, (eds). Nutrition in Pediatrics 4th edn. BC Decker Inc.: Hamilton, ON, Canada, 2008,, pp 577–588.

    Google Scholar 

  28. McKay KO, Waters DL, Gaskin KJ . The influence of newborn screening for cystic fibrosis on pulmonary outcomes in New South Wales. J Pediatr 2004; 147: S47–S50.

    Article  Google Scholar 

  29. Dijk FN, McKay K, Barzi F, Gaskin KJ, Fitzgerald DA . Improved survival in cystic fibrosis patients diagnosed by newborn screening compared to a historical cohort from the same centre. Arch Dis Child 2011; 96: 1118–1123.

    Article  Google Scholar 

  30. Baur LA, Allen JR, Waters DL, Gaskin KJ . Total body nitrogen in prepubertal children. In: Ellis KJ, Eastman JD, (eds) Human Body Composition. Plenum Press: New York, NY, USA, 1993,, pp 139–142.

    Chapter  Google Scholar 

  31. Haas VK, Allen JR, Kohn MR, Clarke SD, Zhang S-H, Briody JN et al. Total body protein in healthy adolescent girls: validation of estimates derived from simpler measures with neutron activation analysis. Am J Clin Nutr 2007; 85: 66–72.

    Article  CAS  Google Scholar 

  32. Baur LA, Waters DL, Allen BJ, Blagojevic N, Gaskin KJ . Nitrogen deposition in malnourished children with cystic fibrosis. Am J Clin Nutr 1991; 53: 503–511.

    Article  CAS  Google Scholar 

  33. Gaskin KJ, Gurwitz D, Durie PR, Corey M, Levison H, Forstner G . Improved respiratory prognosis in patients with cystic fibrosis with normal fat absorption. J Pediatr 1982; 100: 857–862.

    Article  CAS  Google Scholar 

  34. Gaskin KJ, Durie PR, Hill RE, Lee L, Forstner G . Colipase and maximally activated pancreatic lipase in normal subjects and patients with steatorrhea. J Clin Invest 1982; 69: 427–434.

    Article  CAS  Google Scholar 

  35. Gaskin KJ, Durie PR, Hill RE, Lee L, Forstner G . Colipase and lipase secretion in childhood onset pancreatic insufficiency: delineation of patients with steatorrhea secondary to relative colipase deficiency. Gastroenterology 1984; 86: 1–7.

    CAS  PubMed  Google Scholar 

  36. Wilschanski M, Zielenski J, Markiewicz D, Tsui LC, Corey M, Levison H et al. Correlation of sweat chloride concentration with classes of the cystic fibrosis transmembrane conductance regulator gene mutations. J Pediatr 1995; 127: 705–710.

    Article  CAS  Google Scholar 

  37. Waters DL, Dorney S, Gaskin K, Gruca M, O’Halloran M, Wilcken B . Pancreatic function in infants identified as having cystic fibrosis in a neonatal screening program. N Engl J Med 1990; 322: 303–308.

    Article  CAS  Google Scholar 

  38. Gaskin K, Waters D, Dorney S, Gruca M, O’Halloran M, Wilcken B . Assessment of pancreatic function in screened infants with cystic fibrosis. Pediatr Pulmonol Suppl 1991; 7: 69–71.

    Article  CAS  Google Scholar 

  39. Cipolli M, Castellani C, Wilcken B, Massie J, McKay K, Gruca M et al. Pancreatic phenotype in infants with cystic fibrosis identified by mutation screening. Arch Dis Child 2007; 92: 842–846.

    Article  Google Scholar 

  40. Lapey A, Kirkpatrick J, di Sant’Agnese P, Laster L . Steatorrhoea and azotorrhoea and their relation to growth and nutrition in adolescents and young adults with cystic fibrosis. J Pediatr 1974; 84: 328–334.

    Article  CAS  Google Scholar 

  41. Mitchell EA, Quested C, Marks RD, Pinnock RE, Elliott RB . Comparative trial of viokase, pancreatin and Pancrease® pancrelipase (enteric-coated beads) in the treatment of malabsorption in cystic fibrosis. Aust Paediatr J 1982; 18: 114–117.

    CAS  PubMed  Google Scholar 

  42. Gow R, Bradbear R, Francis P, Shepherd RW . Comparative study of varying regimens to improve steatorrhoea and creatorrhoea in cystic fibrosis. Lancet 1981; 1: 1071–1074.

    Article  Google Scholar 

  43. Gaskin KJ . Impact of nutrition in cystic fibrosis. A review. J Pediatr Gastroenterol Nutr 1988; 7 (Suppl 1), 12–17.

    Article  Google Scholar 

  44. Holliday KE, Allen JR, Waters DL, Gruca MA, Thompson SM, Gaskin KJ . Growth of human milk-fed and formula-fed infants with cystic fibrosis. J Pediatr 1991; 118: 77–79.

    Article  CAS  Google Scholar 

  45. Feigel RJ, Shapiro BL . Mitochondrial calcium uptake and oxygen consumption in cystic fibrosis. Nature 1979; 178: 276–277.

    Article  Google Scholar 

  46. Stutts MJ, Knowles MR, Gatzy JT, Boucher RC . Oxygen consumption and ouabain binding-sites in cystic fibrosis nasal epithelium. Pediatr Res 1986; 20: 1316–1320.

    Article  CAS  Google Scholar 

  47. Pencharz P, Hill R, Archibald E, Levy L, Newth C . Energy needs and nutritional rehabilitation in undernourished adolescents and adults with cystic fibrosis. J Pediatr Gastroenterol Nutr 1984; 3 (Suppl 1), 147–153.

    Article  Google Scholar 

  48. Vaisman N, Pencharz PB, Corey M, Canny GJ, Hahn E . Energy expenditure of patients with cystic fibrosis. J Pediatr 1987; 111: 496–500.

    Article  CAS  Google Scholar 

  49. Buchdahl RM, Cox M, Fulleylove C, Marchant JL, Tomkins AM, Brueton MJ et al. Increased resting energy expenditure in cystic fibrosis. J Appl Physiol 1988; 64: 1810–1816.

    Article  CAS  Google Scholar 

  50. Shepherd RW, Holt TL, Vasques-Velasquez L, Coward WA, Prentice A, Lucas A . Increased energy expenditure in children with cystic fibrosis. Lancet 1988; 1: 1300–1303.

    Article  CAS  Google Scholar 

  51. O’Rawe A, McIntosh I, Dodge JA, Brock DJ, Redmond AO, Ward R et al. Increased energy expenditure in cystic fibrosis is associated with specific mutations. Clin Sci 1992; 82: 71–76.

    Article  Google Scholar 

  52. Fried MD, Durie PR, Tsui LC, Corey M, Levison H, Pencharz PB . The cystic fibrosis gene and resting energy expenditure. J Pediatr 1991; 119: 913–916.

    Article  CAS  Google Scholar 

  53. Allen JR, McCauley J, Selby A, Waters DL, Gruca MA, Gaskin KJ . Differences in resting energy expenditure between male and female children with cystic fibrosis. J Pediatr 2003; 142: 15–19.

    Article  Google Scholar 

  54. Magoffin A, Allen JR, McCauley J, Gruca M, Peat J, Van Asperen P et al. Longitudinal analysis of resting energy expenditure in patients with cystic fibrosis. J Pediatr 2008; 152: 703–708.

    Article  Google Scholar 

  55. Barclay A, Allen JR, Blyler E, Prior R, Yap J, Gruca MA et al. Resting energy expenditure in females with cystic fibrosis – is it affected by puberty? Eur J Clin Nutr 2007; 61: 1207–1212.

    Article  CAS  Google Scholar 

  56. Stallings VA . (Editorial) Gender, death and cystic fibrosis: is energy expenditure a component? J Pediatr 2003; 142: 4–6.

    Article  Google Scholar 

  57. Abernathy RS . Bulging fontanelle as presenting sign in csystic fibrosis. Am J Dis Child 1976; 130: 1360–1362.

    Article  CAS  Google Scholar 

  58. Rayner RJ, Tyrell JC, Hiller EJ, Marenah C, Neugebauer MA, Vernon SA et al. Night blindness and conjunctival xerosis caused by vitamin A deficiency in patients with cystic fibrosis. Arch Dis Child 1989; 64: 1151–1156.

    Article  CAS  Google Scholar 

  59. Scott J, Elias E, Moult PJA, Barnes S, Wills MR . Rickets in adult cystic fibrosis with myopathy, pancreatic insufficiency and proximal renal tubular dysfunction. Am J Med 1977; 63: 488–492.

    Article  CAS  Google Scholar 

  60. Hubbard VS, Farrell PM, di Sant’Agnese PA . 25-Hydroxycholecalciferol levels in patients with cystic fibrosis. J Pediatr 1979; 94: 84–86.

    Article  CAS  Google Scholar 

  61. Reiter EO, Brugman SM, Pike JW, Pitt M, Dokoh S, Haussler MR et al. Vitamin D metabolites in adolescents and young adults with cystic fibrosis: effects of sun and season. J Pediatr 1985; 106: 21–25.

    Article  CAS  Google Scholar 

  62. Farrell PM, Bieri JG, Fratantoni JF, Wood RE, di Sant'Agnese PA . The occurrence and effects of human vitamin E deficiency. A study in patients with cystic fibrosis. J Clin Invest 1977; 60: 233–241.

    Article  CAS  Google Scholar 

  63. Elias E, Müller DPR, Scott J . Association of spinocerebellar disorders with cystic fibrosis or chronic childhood cholestasis and low serum vitamin E. Lancet 1981; 2: 1319–1321.

    Article  CAS  Google Scholar 

  64. Sitrin MD, Lieberman F, Jensen WE, Noronha A, Milburn C, Addington W . Vitamin E deficiency and neurologic disease in adults with cystic fibrosis. Ann Intern Med 1987; 107: 51–54.

    Article  CAS  Google Scholar 

  65. Sokol RJ, Reardon MC, Accurso FJ, Stall C, Narkewicz M, Abman SH et al. Fat-soluble vitamin status during the first year of life in infants with cystic fibrosis identified by screening of newborns. Am J Clin Nutr 1989; 50: 1064–1071.

    Article  CAS  Google Scholar 

  66. Komp DM, Selden RF . Coagulation abnormalities in cystic fibrosis. Chest 1970; 58: 501–508.

    Article  CAS  Google Scholar 

  67. Walters TR, Koch HF . Hemorrhagic diathesis and cystic fibrosis in infancy. Am J Dis Child 1972; 124: 641–647.

    CAS  PubMed  Google Scholar 

  68. Shepherd RW, Holt TL, Thomas BJ, Kay L, Isles A, Francis PJ et al. Nutritional rehabilitation in cystic fibrosis: controlled studies of the effects on nutritional growth retardation, body protein turnover and course of pulmonary disease. J Pediatr 1986; 109: 788–794.

    Article  CAS  Google Scholar 

  69. Gunnell S, Christensen NK, McDonald C, Jackson D . Attitudes towards percutaneous endoscopic gastrostomy placement in cystic fibrosis patients. J Pediatr Gastroenterol Nutr 2005; 40: 334–338.

    Article  Google Scholar 

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Gaskin, K. Nutritional care in children with cystic fibrosis: are our patients becoming better?. Eur J Clin Nutr 67, 558–564 (2013). https://doi.org/10.1038/ejcn.2013.20

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